Injecting Ethics into the Public Health Quality Improvement

Injecting Ethics into the Public Health Quality Improvement / Accreditation Movement Kathy Vincent, LCSW Alabama Department of Public Health Ruth Gaare Bernheim, JD, MPH University of Virginia Alan Melnick, MD, MPH, CPH Health Officer, Clark, Cowlitz, Skamania, and Wahkiakum Counties

Overview • Case Example • Public Health Code of Ethics • Crosswalk of Public Health Accreditation and the Public Health Code of Ethics • Discussion

Case Study: Water Supply • • Environmental factors Testing results Studies Health Effects

Case Study: Water Supply (Discussion) Discussion issues we will return to in a few minutes: • What would you do? • What ethical issues are being raised? • How might the accreditation process strengthen your department’s ability to address or respond to this situation?

Case Study: Water Supply Would you act any differently if: • Birth defects associated with mineral Y exposure are small (inguinal hernia, incurving of fifth finger, single palmer crease )? • Mineral Y is also an ingredient in a cola drink widely consumed over many years by people of all ages? • Mineral Y has recently been used as a chemical agent to intentionally contaminate water in Pakistan?

Poll 1 Would you act any differently if a different water source at a high price could supply your city? Yes No

Poll 2 Would you act any differently if a different water source at no extra cost and without shortages could supply your city? Yes No

Linking Accreditation Process & Core Values Accreditation Opportunity for health departments to learn and incorporate quality and performance improvement techniques Quality Improvement Techniques to improve performance and outcomes “Multidisciplinary, systemsfocused, data-driven method of understanding & improving the efficiency, effectiveness, and reliability of public health processes and practices. ” Rand Report ’ 06

Linking Accreditation and Core Values • Focus: Performance measures and outcomes • Depends on the organization's goals, which grow out of an organization’s core values / principles and mission • Internal versus external process

Linking Accreditation and Core Values Lessons from corporate management • Have explicit core values • Define the enduring character of an organization (similar to Declaration of Independence) • Start with descriptive statement of “We deliver X services” and then ask 5 times “why is that important” • Create vision, goals, and measurements from core values Built to Last Collins and Porras

The Seven Factors of Excellence Leadership & Employee Orientation Innovation Response to External Change Vision Mission Core Values Customer & Client Orientation Quality (Accreditation) ) Teamwork From Duncan & Ginter

Legal Issues Public Health Activities and Policies Public Health Ethics Issues Public Health Context

Why Consider Ethics “…laws are often broadly framed, leaving much room for administrative discretion about when to use public health authority and about which intervention is more ethically appropriate when more than one alternative course of action is legally permissible. ” Bernheim RG, Nieburg P, and Bonnie RJ. “Ethics and the Practice of Public Health, ” in Goodman RA (ed. ), LAW IN PUBLIC HEALTH PRACTICE, 2 nd ed. , Oxford, New York, Oxford University Press (2005).

Definitions and Concepts Law in Public Health Provides authority, limitations on state power, incentives and disincentives for behavior Ethics in Public Health Provides ongoing analysis, deliberation about, and justification for public health action and policy Often allows for much professional discretion Often when law is indeterminate

Definitions and Concepts Law • Formal institution § Statutes § Regulations § Court decisions • Public proceedings with a “reasonable person” standard Ethics • Less formal § Moral norms, values § Professional codes § Previous cases • Publicly justifiable positions, based on ethical reasoning

Administrative Discretion Under the Law TB Outbreak in a Community Law • Authority to detain individuals who are non-compliant with the TB treatment regimen Ethics • Decide by case how to use legal authority • Demonstrate when imposing detention that protecting the public’s health overrides an individual’s moral claim • Act with transparency and accountability: “We are imposing detention because…”

What Is The Code? • Has twelve key principles of the ethical practice of public health • Can be cross-walked with public health practice to foster alignment with the Twelve Ethical Principles

Public Health Code of Ethics Background • Development by a workgroup of the Public Health Leadership Society • Process included a broad range of stakeholders from public health practice to academia • Code is a living document http: //www. phls. org

Role of the Code in Accreditation Rationale for including public health ethics in development of each accreditation standard • Accreditation efforts often cite ethical value of accountability • Application of the Principles demonstrates that other values are relevant, such as role of accreditation in increasing transparency and fostering community trust

Role of the Code in Accreditation Flexibility allows public health ethics to be incorporated into different accreditation approaches • Principles do not require particular mechanisms, such as ethics committees, but allow for experimentation with various approaches to community involvement

Role of the Code in Accreditation • Principles can be applied in different areas of public health practice Examples: disease control and public health genomics • Principles are compatible with movements to accredit particular programs Example: accrediting public health research ethics review

Standards Development • Based on the 10 Essential Services • Uses operational definition of a functional local health department (LHD) • Several states developing state-specific standards for LHDs • National Public Health Performance Standards Program (NPHPSP) includes standards for local public health systems • Consistency in standards developed by NACCHO, the states, and NPHPSP

Standard Domains 1. 2. 3. 4. 5. 6. 7. 8. 9. Monitor health status and understand health issues. Protect people from health problems and health hazards. Give people information they need to make healthy choices. Engage the community to identify and solve health problems. Develop public health policies and plans. Enforce public health laws and regulations. Help people receive health services. Maintain a competent public health workforce. Use continuous quality improvement tools to evaluate and improve the quality of programs and interventions. 10. Contribute to and apply the evidence base of public health. 11. Govern and manage health department resources (including financial and human resources, facilities, and information systems).

The Public Health Code of Ethics Principles of the Ethical Practice of Public Health* 1 Public health (PH) should address fundamental causes of disease and requirements for health 2 PH should achieve community health in a way respecting individuals’ rights 3 PH policies, programs, and priorities should be developed / evaluated with community members’ input 4 PH should work to empower disenfranchised community members, aiming to ensure access to basic resources necessary for health * Principles of the Ethical Practice of Public Health, The Public Health Leadership Society (2002), http: //www. phls. org

The Public Health Code of Ethics 5 PH should seek information needed to implement effective policies / programs that protect and promote health 6 PH institutions should provide communities with information needed for policy / program decisions and should obtain community’s consent for implementation 7 PH institutions should act in timely manner within resources and mandate given by public 8 PH programs / policies should incorporate approaches that respect diverse values, beliefs, and cultures in community

The Public Health Code of Ethics 9 PH programs / policies should be implemented in manner that most enhances physical and social environment 10 PH institutions should protect confidentiality of information that can bring harm to individual or community if made public 1 1 PH institutions should ensure their employees’ professional competence 12 PH institutions and their employees should engage in collaborations and affiliations that build public’s trust and institution’s effectiveness

Domain 1 (Monitor health status and understand health issues) Ethical Principles Obtain and maintain data that provide information on the community’s health Health services data, environmental data, data on disparities such as poverty, lack of affordable housing, limited or no access to transportation etc. Analyze data to identify trends, health problems, environmental health hazards, and social and economic conditions that adversely affect the public’s health. 1. Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes 4. Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all. Develop relationships with local providers and others in the community who have information on reportable diseases and other conditions of public health interest and facilitate information exchange. 3. Public health policies, programs and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members. 5. Public health should seek the information needed to implement effective policies and programs that protect and promote health. 6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation. 12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness. Integrate data with health assessment and data collection efforts conducted by others in the public health system. Conduct or contribute expertise to periodic community health assessments. 12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.